To the Editor.—A rare case of appendicitis is reported to illustrate the differential diagnosis of acute symptoms and signs involving mainly the left lower quadrant of the abdomen. The only similar case found in the literature had been diagnosed by exclusion without surgical exploration.1

Report of a Case.—In a 52-year-old man with epigastric aching, nausea, and fever, tenderness was found mainly over the left lower quadrant of the abdomen. He improved temporarily, but four days later took milk of magnesia, and his condition worsened. His temperature was 39.4° C, blood pressure, 110/80, and pulse rate, 90. There was marked tenderness over the lower portion of the abdomen, mainly on the left side. Bowel sounds were hypoactive. A grade-2 systolic injection murmur was heard over the fourth intercostal space in the parasternal area. A white blood cell count was normal. The urine contained glucose (4+ ) and six to